Faculty Bibliography

Adult hospitalized patients are at risk for malnutrition. The sensitivity and specificity of screening tools were compared with Subjective Global Assessment. Methods included a systematic review using PubMed, CINAHL Plus, and EMBASE through April 2014. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies method. The results showed that the Malnutrition Universal Screening Tool, Nutrition Risk Screening-2002, and Malnutrition Screening Tool were most frequently tested. The specificity was generally good (>80%), but sensitivity was variable. Malnutrition Universal Screening Tool, Nutrition Risk Screening-2002, and Malnutrition Screening Tool are screening tools that consider population characteristics and risk cut points and are easy to administer.

Varied diets are diverse with respect to diet quality, and existing dietary variety indices do not capture this heterogeneity. We developed and evaluated the multidimensional US Healthy Food Diversity (HFD) index, which measures dietary variety, dietary quality and proportionality according to the 2010 Dietary Guidelines for Americans (DGA). In the present study, two 24 h dietary recalls from the 2003-6 National Health and Nutrition Examination Survey (NHANES) were used to estimate the intake of twenty-six food groups and health weights for each food group were informed by the 2010 DGA. The US HFD index can range between 0 (poor) and 1 - 1/n, where n is the number of foods; the score is maximised by consuming a variety of foods in proportions recommended by the 2010 DGA. Energy-adjusted Pearson's correlations were computed between the US HFD index and each food group and the probability of adequacy for fifteen nutrients. Linear regression was run to test whether the index differentiated between subpopulations with differences in dietary quality commonly reported in the literature. The observed mean index score was 0.36, indicating that participants did not consume a variety of healthful foods. The index positively correlated with nutrient-dense foods including whole grains, fruits, orange vegetables and low-fat dairy (r 0.12 to 0.64) and negatively correlated with added sugars and lean meats (r - 0.14 to - 0.23). The index also positively correlated with the mean probability of nutrient adequacy (r 0.41; P< 0.0001) and identified non-smokers, women and older adults as subpopulations with better dietary qualities. The US HFD index may be used to inform national dietary guidance and investigate whether healthful dietary variety promotes weight control.

The intake of carbohydrates has been evaluated cross-sectionally, but not longitudinally in an ageing American adult population. The aim of the present study was to examine trends in the intake of dietary carbohydrates and their major food sources among the Framingham Heart Study Offspring (FOS) cohort, which had been uniquely tracked for 17 years in the study. The FOS cohort was recruited in 1971-1975. Follow-up examinations were conducted, on average, every 4 years. Dietary data collection began in 1991 (examination 5) using a validated semi-quantitative FFQ. The study included 2894 adults aged >/= 25 years with complete dietary data in at least three examinations from 1991 to 2008. Descriptive statistics were generated using SAS version 9.3, and a repeated-measures model was used to examine trends in the intake of carbohydrates and their food sources in the whole sample, and by sex and BMI category. Over 17 years of follow-up, the percentage of energy from total carbohydrates (51.0-46.8 %; P for trend < 0.001) and total sugars (18.2-16.6 %; P for trend < 0.001) decreased. There was a decrease in the percentage of energy from fructose (5.4-4.7 %; P for trend < 0.001) and sucrose (9.8-8.8 %; P for trend < 0.001). Dietary fibre intake increased (18.0-19.2 g/d; P for trend < 0.001). The number of weekly servings of yeast bread, soft drinks/soda, cakes/cookies/quick breads/doughnuts, potatoes, milk, pasta, rice and cooked grains, fruit juice/drinks, potato chips/maize chips/popcorn, and lunch foods (e.g. pizzas and burgers) decreased significantly (P for trend < 0.001), while the intake of ready-to-eat cereals, legumes, fruits, dairy products, candy and ice cream/sherbet/frozen yogurt increased significantly (P for trend<0.04). Similar trends were observed when the analyses were stratified by sex and BMI. The present results suggest favourable trends in dietary carbohydrate consumption, but dietary guidelines for fruits, vegetables and fibre were not met in this cohort.

Few longitudinal studies carried out in US adults have evaluated long-term dietary fat intakes and compared them with the national recommendations during the two-decade period when the prevalence of obesity and insulin resistance increased substantively. In the present study, we examined trends in the intakes of dietary fats and rich dietary sources of fats in the Framingham Heart Study Offspring Cohort over a 17-year period. The cohort was established in 1971-75 with follow-up examinations being conducted approximately every 4 years. Dietary data were collected using a semi-quantitative FFQ beginning in 1991 (exam 5). We included 2732 adults aged >/= 25 years with complete dietary data in at least three examinations from 1991 to 2008. Descriptive statistics were generated using SAS version 9.3, and a repeated-measures model was used to examine trends in macronutrient and food intakes using R. Over the 17 years of follow-up, the percentage of energy derived from total fat and protein increased (27.3-29.8 % of energy and 16.8-18.0 % of energy, respectively) and that derived from carbohydrate decreased (51.0-46.8 % of energy; P-trend < 0.001). Increases in the percentage of energy derived from all fat subtypes were observed, except for that derived from trans-fats, which decreased over time (P-trend < 0.001). Trends were similar between the sexes, although women exhibited a greater increase in the percentage of energy derived from saturated fat and less reduction in the percentage of energy derived from trans-fats (P interaction < 0.05). Trends in fat intake were similar across the BMI categories. The number of weekly servings of cheese, eggs, ice cream desserts, nuts, butter and sausages/processed meats increased, whereas the intake of milk, margarine, poultry, confectioneries, chips and breads decreased (P-trend < 0.001). In this cohort of predominantly Caucasian older adults, the percentage of energy derived from dietary fats increased over time, but it remained within the national recommendations of less than 35 % of total energy, on average.

Effective breast cancer management is more complex with diabetes present and may contribute to poor outcomes. Therefore, we conducted two simultaneous systematic reviews to address the association of diabetes with (1) treatment patterns in breast cancer patients and (2) breast cancer recurrence rates or breast cancer-specific and all-cause mortality. We searched major databases for English language peer-reviewed studies through November 2013, which addressed either of the above research questions, following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method. Analyses compared treatment patterns or health outcomes for breast cancer subjects with and without diabetes. We used STROBE quality criteria and conducted a random-effects meta-analysis of all-cause mortality. The review yielded 11 publications for question 1 and 26 for question 2, with nine overlapping. Treatment studies showed chemotherapy was less likely in patients with diabetes. Of 22 studies, 21 assessing all-cause mortality indicated a statistically significant increased overall mortality for patients with diabetes (hazard ratios: 0.33-5.40), with meta-analysis of eligible studies indicating a 52 % increased risk. Nine studies assessing breast cancer-specific mortality had inconsistent results, with five showing significantly increased risk for diabetes patients. Results were inconsistent for recurrence and metastases. The majority of studies reported detrimental associations between diabetes and optimal treatment or all-cause mortality among women with breast cancer. Divergence in variable and outcomes inclusion and definitions, potential participation bias in individual studies, and differing analytic methods make inferences difficult. This review illuminates the importance of the impact of diabetes on breast cancer patients and explicitly recognizes that co-management of conditions is necessary to prevent excess morbidity and mortality.

PURPOSE: Insulin resistance is believed to play an important role in the link between energy imbalance and colon carcinogenesis. Emerging evidence suggests that there are substantial racial differences in genetic and anthropometric influences on insulin-like growth factors (IGFs); however, few studies have examined racial differences in the associations of IGFs and colorectal adenoma, precursor lesions of colon cancer. METHODS: We examined the association of circulating levels of IGF-1, IGFBP-3 and IGFBP-1, and SNPs in the IGF-1 receptor (IGF1R), IGF-2 receptor (IGF2R), and insulin receptor genes with risk of adenomas in a sample of 410 incident adenoma cases and 1,070 controls from the Case Transdisciplinary Research on Energetics and Cancer (TREC) Colon Adenomas Study. RESULTS: Caucasians have higher IGF-1 levels compared to African Americans; mean IGF-1 levels are 119.0 ng/ml (SD = 40.7) and 109.8 ng/ml (SD = 40.8), respectively, among cases (p = 0.02). Mean IGF-1 levels are also higher in Caucasian controls (122.9 ng/ml, SD = 41.2) versus African American controls (106.9, SD = 41.2), p = 0.001. We observed similar differences in IGFBP3 levels by race. Logistic regression models revealed a statistically significant association of IGF-1 with colorectal adenoma in African Americans only, with adjusted odds ratios (ORs) of 1.68 (95 % CI 1.06-2.68) and 1.68 (95 % CI 1.05-2.71), respectively, for the second and third tertiles as compared to the first tertile. One SNP (rs496601) in IGF1R was associated with adenomas in Caucasians only; the per allele adjusted OR is 0.73 (95 % CI 0.57-0.93). Similarly, one IGF2R SNP (rs3777404) was statistically significant in Caucasians; adjusted per allele OR is 1.53 (95 % CI 1.10-2.14). CONCLUSION: Our results suggest racial differences in the associations of IGF pathway biomarkers and inherited genetic variance in the IGF pathway with risk of adenomas that warrant further study.

BACKGROUND: Obesity-related dysregulation of the insulin-glucose axis is hypothesized in carcinogenesis. We studied impaired fasting glucose (IFG) and other markers of insulin-glucose metabolism in the Framingham Heart Study-Offspring Cohort, which uniquely tracks these markers and cancer >37 years. METHODS: Participants were recruited between 1971 and 1975 and followed until 2008 (n = 4,615; mean age 66.8 years in 2008). Serum glucose, insulin, and hemoglobin A1c were determined from fasting blood in quart-annual exams. Lifestyle and demographic information was self-reported. HRs and 95% confidence intervals (CI) of cancer risk were computed using time-dependent survival analysis (SASv9.3), while accounting for temporal changes for relevant variables. RESULTS: We identified 787 obesity-related cancers, including 136 colorectal, 217 breast, and 219 prostate cancers. Absence versus presence of IFG 10 to 20 years and 20+ years before the event or last follow-up was associated with 44% (95% CI, 1.15-1.79) and 57% (95% CI, 1.17-2.11) increased risk of obesity-related cancers, respectively. When time-dependent variables were used, after adjusting for age, sex, smoking, alcohol, and body mass index, IFG was associated with a 27% increased risk of obesity-related cancer (HR = 1.27; CI, 1.1-1.5). Associations were stronger in smokers (HR = 1.41; CI, 1.13-1.76). Increased risk was noted among persons with higher insulin (HR = 1.47; CI, 1.15-1.88) and hemoglobin A1c (HR = 1.54; CI, 1.13-2.10) for the highest (>/=5.73%) versus lowest (2-fold increase in colorectal cancer risk was observed for all blood biomarkers of insulin-glucose metabolism, particularly with earlier IFG exposure. Nonsignificant increased risk of breast and prostate cancer was observed for blood biomarkers. CONCLUSIONS: Earlier IFG exposure (>10 years before) increased obesity-related cancer risk, particularly for colorectal cancer. IMPACT: Our study explicitly recognizes the importance of prolonged IFG exposure in identifying links between glucose dysregulation and obesity-related cancers. Cancer Epidemiol Biomarkers Prev; 22(10); 1-12. (c)2013 AACR.

Humans are exposed to a complex and changing combination of nutritional factors during the life course, necessitating their investigation over time to capture "critical periods of sensitivity." A life course approach provides a framework to examine trajectories and long-term effects of nutritional and other risk factors, particularly the role of timing, accumulation, and temporal relationships of these exposures in relation to chronic disease development. Currently, most epidemiologic research does not sufficiently address this issue in relation to disease etiology. Although applying a life course approach would augment our knowledge about disease development, this approach presents major challenges in designing, conducting, and analyzing studies. A scientific symposium was held that reviewed emerging research and discussed methodological concerns in applying the life course approach. The research presented at this session focused on the role of timing, with the pre- and postnatal and pubertal periods as critical windows of exposure for chronic conditions. Methodological issues and complexities in analyzing and selecting datasets were highlighted. This symposium elucidated unique study designs and statistical strategies to demonstrate the strengths of this methodology, and served as a catalyst for new research in the area of nutrition and chronic disease epidemiology.